Chapter 32. Wound management
Definitions
Abrasion – Removal of part of the surface of the skin. There is often oozing from the capillaries on the surface of the dermis. Conventionally referred to as a ‘graze’
Avulsion – The forced separation of two parts; with wounding, this is when a flap of skin and associated tissue has been partially or completely removed
Amputation – Removal of a portion of a limb or the complete limb
Closed wound – An internal injury caused by a blunt direct force to the surface of the body. The skin itself is intact but there is injury to the underlying tissues
Cut (incised wound) – A breach of the skin caused by a sharp edge
Contused wound – Loss of continuity of the tissue with surrounding bruising
Contusion – An area of bruising due to the effect of a blunt force
Haematoma – An accumulation of blood due to bleeding beneath the skin as a result of a blunt direct force
Healing by primary intention occurs when the edges of the wound are already adjacent or can be brought together (e.g. with sutures or Steri-Strips)
Healing by secondary intention occurs when there is significant tissue loss from the wound and regrowth of skin cover is required. With secondary intention healing wound contraction is more prominent. This can lead to significant deformity or contractures if the defect has been large
Laceration – A tear of the skin caused by a blunt force; it is usually irregular in shape
Puncture wound – A wound with a narrow path made by, for example, a nail
Wound – Any interruption by violence or surgery of the continuity of the external surface of the body or the surface of an internal organ. Strictly, a wound is a disruption of the continuity of tissue.
Factors affecting wound healing
• Age
• Nutrition
• Diseases
• Drugs
• Infection
• Foreign body
• Poor blood supply
• Adhesions, movement and drying
• Ionising radiation
• Hypoxia
• Psychological stress.
Immediate management of wounds
The primary survey comes before dealing with any soft tissue injury.
If there is a penetrating wound to the chest the object must be left in situ (if it has not already been removed).
If there is an open pneumothorax, an Asherman® or Bolin® chest seal or a dressing sealed on three sides must be placed over the wound, thus preventing a sucking chest wound.
Control of external haemorrhage
There are three different kinds of bleeding:
• Arterial
• Venous
• Capillary.
Direct pressure
Constant direct pressure is applied to the wound with a clean, large gauze pad (dry or moist). If a gauze pad is not immediately available a gloved hand can be used initially.
Several layers of gauze can then be placed on the wound and a bandage placed over these layers of gauze to secure them in position.
Elevate the injured area above the heart to reduce blood flow to the area.
Indirect pressure
If the wound is still bleeding, the dressing should not be removed but may be reinforced with further dressings.
If the wound continues to bleed through the dressings indirect pressure may be applied to pressure points.
Five important pressure points are:
• The femoral artery in the groin, which can be compressed against the pelvis
• The brachial artery approximately 2 cm in from the medial epicondyle of the elbow, which can be compressed against the lower end of the humerus
• The superficial temporal artery, which can be palpated just anterior to the tragus of the ear and can be compressed against the temporal bone to reduce bleeding from scalp lacerations on that side
• The supraorbital and supratrochlear arteries supplying the forehead, which can be compressed against the supraorbital margin to reduce bleeding from lacerations of the forehead
• The facial artery, which can be compressed against the mandible approximately halfway from the angle of the mandible to the tip of the chin to reduce bleeding from the lower half of the face.
Splinting is also effective in reducing movement of the limb, thereby reducing the amount of bleeding.
Topical haemostatic agents
Topical haemostatic agents such as Quikclot® Hemcon® or Celox® can be used for the control of severe exsanguinating external haemorrhage. All are highly effective but may be associated with exothermic reactions and tissue damage. They are therefore very much second line agents if direct pressure is insufficient to gain control of bleeding. These agents have been widely used in military environments but are seldom used by UK ambulance services.
Tourniquets
Tourniquets are used as a last resort where the patient is exsanguinating from a limb and it must be tight enough to prevent both arterial and venous flow.
If the tourniquet is too loose it allows arterial flow and leads to venous engorgement in the limb and further bleeding.
A commercially produced tourniquets is always preferable to an improvised tourniquet.
• The tourniquet must be placed as distal as possible, close to the wound, in order to preserve as much of the limb as possible
• The tourniquet must be tightened until no further bleeding occurs. This will be very painful for the patient
• The time of application of the tourniquet, the name of the person applying it and its position must be recorded. The tourniquet must never be covered
• The tourniquet may be loosened after 15 minutes to see if haemostasis has occurred and retightened or removed as indicated.
Control of external haemorrhage of an open wound with a sharp object protruding
When a sharp object is protruding from a wound it must not be removed. Pads or thick dressings are placed around the protruding object to support it and reduce unwanted movement. The dressings are then secured firmly in place.
Bites
The most significant risk in the management of bites is the development of infection, especially in human bites, the most common of which is a laceration over the knuckle from a punch to the face which has struck the opponent’s teeth.
Bites from large animals (including powerful dogs) may be associated with underlying fractures.
Puncture wounds
These wounds are caused by a sharp point and since the wound closes over, they are prone to infection, especially with anaerobic bacteria. These patients need antibiotic cover.
Environment in which the injury occurred
Wounds which are tetanus prone include wounds more than 6 hours old which have not been thoroughly cleaned, those with a large amount of necrotic tissue present and wounds that have been in contact with soil or manure.
Tetanus prophylaxis can be administered in hospital.
The temperature of the environment is also important; frostbite will reduce wound healing.
Time of injury
The longer a wound is left without appropriate cleaning and dressing, the more likely it is to be infected.
In all traumatic wounds, there is an infection rate of approximately 15%.
The chances of wound infection are reduced by clearing debris from the wound, applying a clean sterile dressing or gauze and transferring the patient to an emergency department so that the wound can be cleaned and treated.
Older wounds are more likely to be contaminated and are usually cleaned and allowed to remain open with an appropriate dressing.
Examination
Prehospital examination of the wound includes observation of the size, shape and depth of the wound and of any underlying structures that have been exposed or are protruding from the wound (e.g. bone, tendons, vessels, nerves or subcutaneous tissue).
At the scene, it is important to note movement and sensation distal to the wound so the examining hospital doctor can assess if distal function has deteriorated.
Wounds at specific sites
Scalp wounds
Replace any skin flaps and to provide direct pressure on the site of the wound with a sterile gauze and secured with a bandage. In the absence of other injuries, these patients are best transferred sitting up.
Neck wounds
Neck wounds may be associated with airway compromise due to pressure from external bleeding or bleeding into the airway, pneumothorax (simple or tension), shock or severe damage to underlying structures. Foreign bodies should be left in situ and a simple dressing applied.
If there is an air leak, an occlusive dressing must be applied to prevent air embolism. Direct pressure may be necessary to control bleeding, but simultaneous pressure on both carotids must be avoided.
Wounds of the palm of the hand
A sterile pad should be placed over the wound, with the patient’s fingers over the gauze to apply pressure over the injury. The fingers can then be bandaged down. The limb should be elevated.
Eye wounds
Any contusion, laceration or penetrating wound to the eye should be covered by a sterile dressing and the sterile dressing bandaged in situ.
Lacerations to the eyelids should be kept moist with damp gauze.
The bandage should ideally cover both eyes as this prevents any consensual movement of the eye which could cause further damage.
Varicose vein injuries in the lower leg
Direct pressure should be applied to the wound with gauze, the patient should be laid down and the leg elevated during transfer.
Management of specific types of wounds
Flap wounds
It is important to make sure that the flaps are replaced and that a sterile gauze dressing, dry or moist, is placed over the top.
Foreign body wounds
If there is a large impaled object then this should not be removed and a dressing should be applied around the area.
A small foreign body, either glass or grit, on the surface which is not embedded, can be removed.
If small particles of glass or grit are embedded these will be more difficult to remove and a sterile dressing, dry or moist, should be placed over the wound and the personnel at the hospital notified on arrival.
Crush injuries
Fingertip crush injuries are common and cause local tissue damage, often with an underlying fracture and marked swelling.
The injured digit should be covered with either a dry dressing or a moist saline soak, elevated and the patient taken to hospital.
With extensive crush injuries to the limbs toxins may be released once the crush has been released. Before the patient is released (or en route to hospital if this is not possible) fluid resuscitation should be commenced.
If life-threatening thoraco-abdominal bleeding is present, give 250 mL aliquots of normal saline to maintain the presence of a radial pulse.
In the absence of thoraco-abdominal bleeding a patient with a severe crush injury should receive IV fluids (2 litres in an adult, 20 mL/kg in a child).
Intravenous opiate analgesia is likely to be required to control pain.
High-pressure injection injuries
Injuries may occur from a high-pressure oil or grease gun and initially very little injury may be evident. However, these injuries must be seen in hospital as there may be severe damage and necrosis to the tissue underlying the skin. These injuries can lead to extensive loss of soft tissue.
Amputation
When either a limb or a digit has been completely severed there can be massive bleeding, but bleeding is usually limited as the vessels go into spasm and retract into the wound.
The area should be covered with a sterile saline soak or sterile gauze, direct pressure applied and the stump elevated.
The amputated part should be wrapped in a polythene bag. The bag can then be placed in a second bag which can then be placed in iced water.
It is important not to place the amputated part directly in contact with either cotton wool, gauze or ice as this will cause tissue damage or contamination.
Abrasions
The abrasion should be covered with a sterile dressing, preferably moist, and the patient transferred to hospital so that the abrasion can be cleaned adequately under local anaesthesia.
Contusions
Where there are severe contusions to a limb, hand or digit, the injured part should be immobilised in a splint, elevated and, where possible, ice or a cold compress used to alleviate the pain and swelling.
For further information, see Ch. 32 in Emergency Care: A Textbook for Paramedics.
